NUR 230 Final Exam V2 | NUR 230 The
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Final Exam) |
Galen College of Nursing
1. A nurse is assessing a pregnant client who reports her last menstrual period began on May
10th. Using Naegele’s Rule, what is the estimated date of delivery (EDD)?
A. February 17th
B. February 3rd
C. February 10th
D. January 17th
Answer: A
Rationale: Naegele’s Rule is calculated by subtracting three months from the first day of
the last menstrual period and then adding seven days and one year. For a client with an
LMP of May 10th, subtracting three months results in February, and adding seven days
leads to February 17th. This method assumes a standard 28-day cycle and is the primary
tool used in clinical practice to estimate the due date.
2. A nurse is caring for a client in the first stage of labor and notes the fetal heart rate (FHR)
monitor shows late decelerations. Which of the following is the priority nursing action?
A. Administer oxygen at 8-10 L/min via non-rebreather mask
,B. Perform a vaginal exam to check for cord prolapse
C. Increase the rate of the maintenance IV fluids
D. Position the client in a side-lying position
Answer: D
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which requires
immediate intervention to improve fetal oxygenation. Repositioning the client to the lateral
side-lying position is the first action to relieve pressure on the inferior vena cava and
improve blood flow. Subsequent actions include increasing IV fluids, administering oxygen,
and notifying the healthcare provider if the pattern persists.
3. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. The nurse
notes the client has absent deep tendon reflexes (DTRs) and a respiratory rate of 10/min.
Which medication should the nurse prepare to administer?
A. Naloxone
B. Terbutaline
C. Calcium Gluconate
D. Hydralazine
Answer: C
Rationale: Absent DTRs and respiratory depression are classic signs of magnesium sulfate
toxicity. Calcium gluconate is the specific antagonist for magnesium and should be kept at
,the bedside whenever magnesium sulfate is infusing. The nurse must stop the infusion
immediately and notify the provider while preparing the antidote for administration.
4. A postpartum nurse is assessing a client 4 hours after delivery and finds the fundus is firm,
two fingerbreadths above the umbilicus, and deviated to the right. Which action should the
nurse take?
A. Assist the client to the bathroom to void
B. Administer an oxytocic agent as ordered
C. Massage the fundus until it becomes firm
D. Notify the provider of a suspected hemorrhage
Answer: A
Rationale: A fundus that is displaced above the umbilicus and to the right is a classic sign
of bladder distention. A full bladder prevents the uterus from contracting effectively, which
increases the risk of postpartum hemorrhage. Assisting the client to empty her bladder will
typically return the fundus to the midline and its appropriate level.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should be
reported to the provider as a sign of respiratory distress?
A. Nasal flaring
B. Respiratory rate of 50/min
C. Acrocyanosis
, D. Abdominal breathing
Answer: A
Rationale: Nasal flaring is a compensatory mechanism used by newborns to increase the
volume of inspired air during respiratory distress. Other signs include grunting,
retractions, and a respiratory rate consistently above 60/min. Acrocyanosis and abdominal
breathing are considered normal physiological findings in the immediate neonatal period.
6. A nurse is reviewing the GTPAL for a client who is currently pregnant, has a 5-year-old child
born at 38 weeks, and had a miscarriage at 10 weeks gestation. How should the nurse
document this?
A. G2, T0, P1, A1, L2
B. G2, T1, P0, A1, L1
C. G3, T0, P1, A1, L1
D. G3, T1, P0, A1, L1
Answer: D
Rationale: The Gravida (G) includes all pregnancies, including the current one, which
makes it 3. Term (T) births are those occurring at 37 weeks or later (1), while Abortions
(A) include miscarriages before 20 weeks (1). Since the client has one living child, the
Living (L) count is 1, resulting in G3, T1, P0, A1, L1.
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Final Exam) |
Galen College of Nursing
1. A nurse is assessing a pregnant client who reports her last menstrual period began on May
10th. Using Naegele’s Rule, what is the estimated date of delivery (EDD)?
A. February 17th
B. February 3rd
C. February 10th
D. January 17th
Answer: A
Rationale: Naegele’s Rule is calculated by subtracting three months from the first day of
the last menstrual period and then adding seven days and one year. For a client with an
LMP of May 10th, subtracting three months results in February, and adding seven days
leads to February 17th. This method assumes a standard 28-day cycle and is the primary
tool used in clinical practice to estimate the due date.
2. A nurse is caring for a client in the first stage of labor and notes the fetal heart rate (FHR)
monitor shows late decelerations. Which of the following is the priority nursing action?
A. Administer oxygen at 8-10 L/min via non-rebreather mask
,B. Perform a vaginal exam to check for cord prolapse
C. Increase the rate of the maintenance IV fluids
D. Position the client in a side-lying position
Answer: D
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which requires
immediate intervention to improve fetal oxygenation. Repositioning the client to the lateral
side-lying position is the first action to relieve pressure on the inferior vena cava and
improve blood flow. Subsequent actions include increasing IV fluids, administering oxygen,
and notifying the healthcare provider if the pattern persists.
3. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. The nurse
notes the client has absent deep tendon reflexes (DTRs) and a respiratory rate of 10/min.
Which medication should the nurse prepare to administer?
A. Naloxone
B. Terbutaline
C. Calcium Gluconate
D. Hydralazine
Answer: C
Rationale: Absent DTRs and respiratory depression are classic signs of magnesium sulfate
toxicity. Calcium gluconate is the specific antagonist for magnesium and should be kept at
,the bedside whenever magnesium sulfate is infusing. The nurse must stop the infusion
immediately and notify the provider while preparing the antidote for administration.
4. A postpartum nurse is assessing a client 4 hours after delivery and finds the fundus is firm,
two fingerbreadths above the umbilicus, and deviated to the right. Which action should the
nurse take?
A. Assist the client to the bathroom to void
B. Administer an oxytocic agent as ordered
C. Massage the fundus until it becomes firm
D. Notify the provider of a suspected hemorrhage
Answer: A
Rationale: A fundus that is displaced above the umbilicus and to the right is a classic sign
of bladder distention. A full bladder prevents the uterus from contracting effectively, which
increases the risk of postpartum hemorrhage. Assisting the client to empty her bladder will
typically return the fundus to the midline and its appropriate level.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should be
reported to the provider as a sign of respiratory distress?
A. Nasal flaring
B. Respiratory rate of 50/min
C. Acrocyanosis
, D. Abdominal breathing
Answer: A
Rationale: Nasal flaring is a compensatory mechanism used by newborns to increase the
volume of inspired air during respiratory distress. Other signs include grunting,
retractions, and a respiratory rate consistently above 60/min. Acrocyanosis and abdominal
breathing are considered normal physiological findings in the immediate neonatal period.
6. A nurse is reviewing the GTPAL for a client who is currently pregnant, has a 5-year-old child
born at 38 weeks, and had a miscarriage at 10 weeks gestation. How should the nurse
document this?
A. G2, T0, P1, A1, L2
B. G2, T1, P0, A1, L1
C. G3, T0, P1, A1, L1
D. G3, T1, P0, A1, L1
Answer: D
Rationale: The Gravida (G) includes all pregnancies, including the current one, which
makes it 3. Term (T) births are those occurring at 37 weeks or later (1), while Abortions
(A) include miscarriages before 20 weeks (1). Since the client has one living child, the
Living (L) count is 1, resulting in G3, T1, P0, A1, L1.
